Antenatal - Pre-eclampsia

Question 1

what is pre-eclampsia and when does it occur?

Answer 1

• new high blood pressure in pregnancy with end organ dysfunction - proteinuria
• occurs after 20 weeks gestation when the spiral arteries of the placenta from abnormally which causes high vascular resistance in these vessels

Question 2

without treatment what can pre-eclampsia cause?

Answer 2

maternal organ damage
fetal growth restriction
seizures
early labour
death

Question 3

what is the triad of pre-eclampsia?

Answer 3

hypertension
proteinuria
oedema

Question 4

what is chronic hypertension?

Answer 4

high blood pressure that exists before 20 weeks gestation and is longstanding

NOT caused by dysfunction in the placenta

NOT classed as pre-eclampsia

aim for 140-150/80-90

Question 5

what is pregnancy-induced hypertension or gestational hypertension?

Answer 5

hypertension occurring after 20 weeks gestation WITHOUT proteinuria

>140/90 or diastolic >110

2 readings 4 hours apart

Question 6

management of hypertension in pregnancy

Answer 6

aspirin from 12 weeks - 38 weeks

change the meds - labetalol, methyldopa

weekly urine dip, FBC, U&E, LFT, manual BP

4 weekly growth scan from 28 weeks

monitor BP at birth

cant use Ergometrine in HTN

Question 7

what is eclampsia?

Answer 7

when seizures occur as a result of pre-eclampsia

Question 8

how are the risk factors for pre eclampsia use to decide whether prophylaxis is required?

Answer 8

• used to determine whether women are offered aspirin
• from 12 week until birth if they have 1 high-risk factor or more than 1 moderate-risk factor

Question 9

what medication is contraindicated in delivery in hypertension?

Answer 9

Ergometrine

Question 10

what are the high-risk factors for pre-eclampsia?

Answer 10

• Autoimune
• Before in pregnancy HTN - previous HTN in pregnancy
• CKD
• Diabetes
• Existing HTN

Question 11

what are the moderate-risk factors for pre-eclampsia?

Answer 11

• older than 40
• BMI >35
• >10 years since previous pregnancy
• multiple pregnancy
• first pregnancy
• family hx of pre-eclampsia
• low pappa
• uterine artery notching

Question 12

what are the symptoms of pre-eclampsia?

Answer 12

• headache
• visual disturbance or blurriness
• nausea and vomiting
• upper abdominal pain - over liver area from liver swelling (make this clear in exams they know you’re talking about liver pain - epigastric pain can be anything)
• oedema
• reduced urine output
• brisk reflexes

Question 13

what is the criteria for diagnosis of pre-eclampsia?

Answer 13

• systolic >140 or diastolic >90

PLUS any of

• proteinuria (1+ or more on dipstick)
• organ dysfunction (raised creatinine, elevated liver enzymes, seizures, thrombocytopenia or haemolytic anaemia)
• placental dysfunction (FGR or abnormal Doppler studies

Question 14

how can proteinuria be quantified?

Answer 14

• urine protein:creatinine ratio (>30mg/mmol is significant)
• urine albumin:creatinine ratio (>8mg/mmol is significant)

Question 15

what can be used between 20 and 35 weeks gestation to rule-out pre-eclampsia?

Answer 15

placental growth factor (PlGF) which is released by the placenta and functions to stimulate the development of new blood vessels

low in pre-eclampsia

NICE recommend this test on 1 occasion during pregnancy in women suspected of having pre-eclampsia

Question 16

what are women routinely monitored for at every antenatal appointment for evidence of pre-eclapmsia?

Answer 16

blood pressure

symptoms

urine dipstick for proteinuria

Question 17

what is the management of gestational hypertension

Answer 17

• treat to aim for a blood pressure below 135/85
• admission for women with blood pressure above 160/110
• urine dipstick weekly
• monitoring of blood weekly (FBC, UE, LFT)
• monitor fetal growth by serial growth scans
• PlGF testing on one occasion

Question 18

how is pre-eclampsia managed?

Answer 18

• aspirin prophylaxis
• scoring system used to determine whether to admit
• blood pressure monitored closely (every 48 hours)
• urine dipstick testing not routinely necessary as dx already made
• UUS of fetus, amniotic fluid and dopplers performed 2 weekly

Question 19

what scoring systems can be used for pre-eclapmsia?

Answer 19

fullPIERS

PREP-S

Question 20

medical management of pre-eclampsia and what are some medications that can be used in pre-eclampsia?

Answer 20

• Labetolol 1st line
• Nifedipine (modified-release) second-line - better response in black population
• Methyldopa third-line (needs to be stopped within two days of birth)
• IV magnesium sulphate is given during labour and in the 24 hours afterwards to prevent seizures
• Fluid restriction is used during labour in severe pre-eclampsia or eclampsia, to avoid fluid overload

Question 21

what can be used in the critical care setting for severe pre-eclampsia or eclampsia?

Answer 21

Intravenous hydralazine may be used as an antihypertensive in critical care in severe pre-eclampsia or eclampsia

Question 22

what may be required if there are complications or the blood pressure cannot be controlled?

Answer 22

planned early delivery of the baby

Question 23

in pre-eclampsia, the blood pressure will return to normal over time once the placenta is removed. what medical treatment can be used after delivery?

Answer 23

• Enalapril 1st line
• nifedipine or amlodipine - first line in black African or Caribbean pt
• Labetalol or atenolol

Question 24

how are the seizures of eclampsia managed?

Answer 24

IV magnesium sulphate

Question 25

what is HELLP Syndrome?

Answer 25

combination of features that occurs as a complication of pre-eclampsia

Haemolysis

Elevated Liver enzymes

Low Platelets

Question 26

what is pre-eclampsia-like syndrome (aka mirror syndrome)

Answer 26

rare complication of severe fetal heart failure

triad of hydrops fetalis, placental oedema and oedema in the mother

also features of hypertension and proteinuria

woman suspected of parvovirus infection need tests for IgM, IgG, and rubella antibodies (as a differential)